Prehabilitation helps people improve their functional capacity through optimising their physical and psychological health.

Studies have shown that people with low fitness and poor eating habits have an increased risk of complications following surgery. This can result in further operations or delayed recovery.

This can be particularly important after a work injury, with time off work or on reduced duties. Many employees lose physical fitness and gain weight, increasing the chance of a poor outcome from surgery. Research has shown the chance of poor result in compensable cases is about four times higher than for non-compensable cases.  

Prehabilitation is generally a home-based program which is conducted in the four to five weeks prior to surgery, and approximately eight weeks after surgery. It might include an exercise program, including both aerobic and resistance exercises, as well as advice on consuming a healthy diet and stress reduction.

The exercise regime is designed to improve fitness through increasing aerobic capacity as well as developing muscle and core strength. 

People with poor diets tend to have a higher complication rate. If the diet is optimised prior to surgery it can compensate for the catabolic response following surgery. The catabolic response includes the breakdown of muscle protein, so the diet may help prevent the loss of lean muscle mass and strength. 

An assessment of the patient’s usual diet can be completed by asking the person to keep a three day diary of their food intake.  

Anxiety reduction approaches can also assist.  Many people are worried about an uncertain outcome and the possibility of complications. Stress, worry and pessimism have been associated with delayed recovery, complications and slow healing following surgery. 

RESEARCH ON PREHABILITATION:

Here are few examples of prehabiliation studies, which highlight the components of prehabiliation and relevant results.  

Lumbar Surgery

Research published in 2008 looked at 60 patients undergoing lumbar spinal fusion surgery. 28 of these patients were randomly chosen to be a part of the intervention group and 32 in the standard care program as the control group.

Patients in the intervention group, receiving prehabilitation and early rehabilitation, obtained their post-operative milestones sooner and returned to work sooner. They also required less primary care after discharge. Their overall care was less costly, even with the intervention program expense added.

The prehabilitation included lifestyle interventions (including tobacco cessation and alcohol reduction), as well as information and instruction, optimisation of pain treatment, physiotherapy and dietary advice.

Hip Replacement

The American Academy of Orthopaedic Surgeons reported finding that prehabilitation reduces the need for perioperative care following a hip replacement by 30%. This was determined through exploring Medicare (US) claims data, identifying preoperative physical therapy and post-operative care usage patterns. 4733 patients were studied.

Colorectal Surgery

A study published in 2014 found that exercising, healthy eating and relaxation techniques prior to surgery helped to speed up a patient’s recovery time post-surgery. The study included 38 participants who took part in prehabilitation and 39 patients in the control group. The prehabilitation group took part in 50 minutes of aerobic activity at least three times each week, as well as consuming a personalised nutrition diet and engaging in relaxation activities.

At the start of the study, both groups could walk an average of 425 metres in six minutes. Immediately before and two months after the operation, the intervention group could walk significantly further. Two months after surgery, the control group walked 22 metres less than they could at the start of the study, and the intervention group could walk 23 metres further. The lead author of the study believes that “Prehabilitation enables patients to withstand the stress of surgery so they are able to recover faster and function better after the procedure.”

WHAT CAN YOU DO?

Prehabilitation is not routinely considered or implemented in everyday surgical practice.  There are therefore few specialised services that offer such an approach. 

RTW Coordinators, Rehabilitation professionals and case managers can help employees with such approaches. The options vary, according to the person you are working with, their treating doctor, and the availability of everyday services.  

Here are some options to assess and consider:

• Get to know the person due to undergo surgery
• Discuss the benefits of being physically and mentally prepared
• How do they rate their normal fitness level, has their fitness dropped since their injury?
• What exercise do they normally do?
• How motivated are they to optimise their recovery?
• Do they need assistance to improve their fitness? If so, do you have a physiotherapist or exercise physiologist you can engage (with their treating practitioner’s agreement) who can set them up with an appropriate fitness program?
• What is their diet like, how can it be improved if poor? Would they benefit from discussing this with their doctor, or seeing a dietician?
• Are they a smoker? Would they benefit from assistance in quitting, at least before and after surgery?
• Have they had all their questions about surgery answered? Do they need more information?  Do they have a clear picture of their post-operative recovery course? (many people don’t)
• Identify those who are particularly worried. This could be through a conversation or their practitioner could have them complete a questionnaire that aides in identifying people who are anxious or fear avoidant (avoid activities that cause pain, worried the activities may be doing harm)

The bigger the operation the more important this approach becomes. Someone who has had a cartilage tear in the knee and has surgery a week after the injury is likely to have a low complication rate regardless of prehabilitation, however someone who has had activity limitations for a year with back pain and sciatica has a better chance of doing better with prehabilitation.